Nokea
When the nurse walks into a client's room, the client states, 'I just love hot-blooded redheads.' The client pats his bed and says, 'Why don't you sit down here and get off your feet for a while.'
Which of the following responses by the nurse is BEST?
- A. I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job.'
- B. I don't think my husband or your wife would like me doing that.'
- C. You must be very lonesome. I'll come back later and spend some time with you.'
- D. I bet you flirt with all the nurses like that.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-nurse should confront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior
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The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?
- A. Supportive and helpful to the victim.
- B. Disconnected and apathetic toward the victim.
- C. Frustrated and feeling vulnerable, but denying need for help.
- D. Emotionally distressed and needing assistance.
Correct Answer: D
Rationale: sexual assault by rape is a crisis situation for both victim and family members and friends
The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?
- A. I usually avoid driving at night since lights sometimes seem to make things blur.'
- B. I take half of the usual dose for my sinuses to maintain my blood pressure.'
- C. I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.'
- D. I take extra fiber and drink lots of water to avoid getting constipated.'
Correct Answer: D
Rationale: I take extra fiber and drink lots of water to avoid getting constipated.' Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.
A client with end stage renal disease has been managed by peritoneal dialysis. Which finding should be reported to the doctor immediately?
- A. The amount of dialysate return is less than that instilled.
- B. The client complains of abdominal pain and nausea.
- C. The dialysate return is colorless in appearance.
- D. The client has lost two pounds in the last week.
Correct Answer: B
Rationale: Complaints of abdominal pain, nausea, fever, and return of cloudy dialysate should be reported to the physician since they are indications of peritonitis. Diminished or slow return of dialysate, as mentioned in answer A, is managed by having the client turn side to side or move about to facilitate return flow, so it is incorrect. Answers C and D are favorable findings that do not require intervention; therefore, they are incorrect.
The nurse is caring for a client with a history of hyperthyroidism.
- A. Which assessment finding is expected in a client with untreated hyperthyroidism?
- B. Bradycardia and weight gain.
- C. Tremors and heat intolerance.
- D. Fatigue and cold intolerance.
- E. Constipation and dry skin.
Correct Answer: B
Rationale: Tremors and heat intolerance are classic symptoms of hyperthyroidism due to increased metabolism. Bradycardia, weight gain, fatigue, and constipation are associated with hypothyroidism.